Deck Cadet Service

SEAFARER'S APPLICATION FORM - Page * of * - PERSONAL DATA

PERSONAL INFORMATION

Family Name Urbanovich First Name (s) Hanna

Birth Date 25-05-1993 Birth Place Grodno

Nationality Belarusian Religion Catholic

Marital Status Single No. of Children ---

Height (cm) 157 Weight (kg) 51

Parents names(first)

Henrykh, Sviatlana Mother maiden n. Nikiforova

ADDRESS (include telephone country & area codes, advise also secondary or contact addresses if any) Street & Nr. Yanki Kupaly 84 Email Address ************@*****.*** Location Mobile Phone +375*********

City Grodno Residence Phone

State, Country Republic of Belarus Fax

Postal (ZIP) Code 230010 Nearest airport Minsk

NEXT OF KIN INFORMATION (person to contact in case of emergency & insurance beneficiary) Family Name Urbanovich First Name(s) Henrykh

Nationality Belarussian Relationship Father

Street & Nr. Yanki Kupaly 84 Email Address ---

Location Mobile Phone +375*********

City Grodno Residence Phone

State, Country Republic of Belarus Fax

Postal (ZIP) Code 230010 P.O. Box (if any)

REMARKS

Requested Rank Deck Cadet Availability Date 01.03.2016 - 01.03.2017 Prefer. Vessel Type --- Minimum Salary ---

English Language Skills Intermediate

Other Foreign Languages Polish, Russian

Professional School / Academy

- Name & Period (From - To)

Maritime Academy in Szczecin

Period from 2013 to 2017

Foreign Crew Experience

(specify nationalities)

---

Other Skills

Further Remarks

I hereby affirm that all the information provided by me in this application is true and correct to the best of my knowledge. Date:22.02.2016

Signature: Urbanovich

SEAFARER'S APPLICATION FORM - Page 2 of 3 - LIST OF DOCUMENTS Please note that due to legal requirements boarding is only possible once we are in possession of photo copies of all listed documents and certificates - in urgent cases you may therefore have to send them by courier, fax or email (.jpg format, scans max. 600 pixel wide or 900 pixel high). Passport photos may arrive later (by mail). Family

Name

Urbanovich First

Name(s)

Hanna Rank DECK CAD. / OS

A. TRAVEL DOCUMENTS AND MEDICAL CERTIFICATES

Document Name (Desciption) Document Number Country Issue Place Issue Date Exp. Date Passport KH2398524 Belarus Grodno 28-05-2014 28-05-2024 Seaman's Book (national) 0263592

Poland Szczecin 31-03-2014 31-12-2019

Seaman's Book (flag state)

Seaman's Book (flag state)

Visa - United States (type C1/D)

Visa - Others (Work/Resid. Permits) RP8161833 Poland Szczecin 29-09-2014 29-09-2024 Medical Examination Report

Drug & Alcohol Test

Vaccination against Yellow Fever Poland Szczecin 07-03-2016 07-03-2026 Vaccination against Cholera

Passport Photos

Document Name (Desciption)

Basic Safety Training Certificate UMS-542*-******- 13557/2013

Poland Szczecin 03-10-2013 10-09-2018

Certificate of Proficiency for

seafarers with designated security

duties

UMS-135*-******-

11916/2014

Poland Szczecin 12-03-2014 indefinitely

Certificate of Proficiency in Security-

awareness

UMS-135*-******-

12029/2014

Poland Szczecin 12-03-2014 indefinitely

HEALTH CERTIFICATE FOR

SERVICE AT SEA

980/15 Poland Szczecin 25-11-2015

25-11-2017

Navigational Watch Certificate UMS-131**-******-

3629/2015

Poland Szczecin 02-11-2015 indefinitely

Certificate of Training in Oil and

Chemical Tanker Familiarization

UMS-133*-******-

4069/2016

Poland Szczecin 23-02-2016 indefinitely

Certificate of Training in Liquified

Gas Tanker Familiarization

UMS-130*-******-

4321/2016

Poland Szczecin 25-02-2016 indefinitely

Date:22.02.2016

Signature: Urbanovich

SEAFARER'S APPLICATION FORM - Page 3 of 3 - SEA SERVICE (LAST 5 YEARS) Please indicate your sea service in the last 5 years as exact as possible - required are the actual sign-on and sign-off dates according to the service certificates resp. seaman's book entries. To speed up processing kindly indicate phone and/or fax numbers of your previous employers. Ship sizes are to be indicated in gross tons, total engine output in kilo Watt

(1 kW = 1.34 bhp) to go along with STCW limitations. Please be prepared to provide evidence for sea service that cannot be confirmed by reference check. The provided may be passed on to our clients and to flag state administrations to allow for verification of rank experience. Please use the European date format (DD.MM.YY). Vessel's Name Flag GT kW Ship Type Rank S/On Date S/Off Date Employer (company to contact for reference)

M/F WOLIN Bahama 228**-***** Passenger DECK CADET 14.08.2014 11.09.2014 Unity Line S/V DAR MŁODZIEŻY Poland 2255 1500 Training

ship

DECK CADET 17.02.2015 09.03.2015 AM Gdynia

M/S NAWIGATOR XXI Poland 1245 1120 Training

ship

DECK CADET 31.08.2015 06.09.2015 AM Szczecin

Date:22.02.2016

Signature:Urbanovich

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